Form 763 - Virginia Nonresident Income Tax Return - 2012
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1
22012
Staple Here
763
*VA0763112888*
Virginia Nonresident Income Tax Return
Page1
Due May 1, 2013
Attach a complete copy of your federal tax return and all other required Virginia attachments.
First Name
MI
Last Name
Suffix
Your Social Security Number
Check if
deceased
Spouse's First Name (Filing Status 2 Only)
MI
Last Name
Suffix
Spouse's Social Security Number
Check if
deceased
Present Home Address (Number and Street or Rural Route)
State of Residence
City, Town or Post Office
State
ZIP Code
Important - Name of Virginia City or County in which principal place of business, employment or income
Locality Code from Instructions
source is located
City OR
County
Your Home Phone Number
Your Business Phone Number
Spouse’s Business Phone Number
Preparer’s PTIN
Filing Election
Code
I(we) authorize the Department of Taxation to discuss my (our) return with my
(our) preparer.
Check Applicable
Amended Return
Overseas on Due Date
Name(s) And Address Different Than
Boxes:
Check if Result of NOL
Shown on 2011 VA Return
Qualifying Farmer, Fisherman or Merchant Seaman
Dependent on Another’s
EIC Claimed on federal return
Return
$
.00
EXEMPTIONS (Enter Number below)
You
Filing Status (Check Only One)
Dependents
65 or over Blind
Total Section 2
Total Section 1
1 +
=
X $930 =
+
=
X $800 =
(1) Single-
h
Did you claim federal head of household? YES
(2) Married, Filing Joint Return -
BOTH must have Virginia
2 +
=
X $930 =
+
=
X $800 =
source income
(3) Married, Spouse Has No Income From Any Source-
2 +
=
X $930 =
+
=
X $800 =
Enter Spouse's SSN above
Spouse's full name
(4) Married, Filing Separate Returns -
1 +
=
X $930 =
+
=
X $800 =
Enter Spouse's SSN above
Spouse's full name
Add the Total of Section 1 plus the Total of Section 2. Enter the sum on Line 13
Your Birth Date
Spouse’s Birth Date
Date of Birth
-
-
-
-
(mm-dd-yyyy)
(mm-dd-yyyy)
1 Adjusted Gross Income. .......................................................................................................................................
1
00
2 Additions from Schedule 763 ADJ, Line 3. ...........................................................................................................
2
00
3 Add Lines 1 and 2. .............................................................................................................................................
3
00
4 Age Deduction (See instructions and the Age Deduction Worksheet).
You
4a
00
Enter Birth Dates above. Enter Your Age Deduction
on Line 4a and Your Spouse's Age Deduction on Line 4b. ...............................................................
Spouse
4b
00
5
00
5 Social Security Act and equivalent Tier 1 Railroad Retirement Act benefits reported on your federal return. .....
6 State income tax refund or overpayment credit reported as income on your federal return. ...............................
6
00
00
7 Subtractions from Schedule 763 ADJ, Line 7. .....................................................................................................
7
8 Add Lines 4a, 4b, 5, 6 and 7. .............................................................................................................................
8
00
9 Virginia Adjusted Gross Income (VAGI). Subtract Line 8 from Line 3. .........................................................
9
00
10 Deductions: Enter total Federal Itemized Deductions from Federal Schedule A. ......................................... .......
10
00
11 State and Local income taxes claimed from Federal Schedule A, if claiming Itemized Deductions. ...................
11
00
12 If claiming Itemized Deductions subtract Line 11 from Line 10 or enter Standard Deduction amount. ...............
12
00
00
13 Exemption amount. Enter the total amount from the Exemption Sections 1 and 2 above. .................................
13
14 Deductions from Schedule 763 ADJ, Line 9. .......................................................................................................
14
00
15 Add Lines 12, 13, and 14. ..................................................................................................................................
15
00
For Local Use
Va. Dept. of Taxation
LTD
_________
$
2601044 REV. 06/12
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